Provider Demographics
NPI:1851768303
Name:BLACK, BRETT (MOT, OT/L)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:MOT, OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 SW BARN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-9378
Mailing Address - Country:US
Mailing Address - Phone:501-230-2050
Mailing Address - Fax:
Practice Address - Street 1:4497 W PECAN ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-7909
Practice Address - Country:US
Practice Address - Phone:501-230-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A1000224Z00000X
AROT2023-028225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant